Cardiovascular Catheterization Report Prototype v. 1.5 Box 1 Box 2

Cardiovascular Catheterization Report Prototype v. 1.5

Cardiac Catheterization Laboratory [Name of facility]

[Logo of facility]

Patient: Last name, first name

[middle initial /name]

MRN: xxxxxxxxx DOB: xx/xx/xxxx Age: xx

Gender: M/F

Procedure Date: xx/xx/xxxx

Cine Number: xxxxx

Cath Attending: xxxxxxxxx xxxxxxxxx

Referring Provider(s): xxxxxxxxxx xxxxxxxxx

Cardiac Catheterization Procedure Report Summary

Primary Indication Chest pain (786.50)

History A 57-year old man with hyperlipidemia, hypertension, and a positive family history who presents

with typical chest discomfort with exertion relieved with rest. A stress echocardiogram was positive

for a large area of ischemia involving the anterior and anterolateral distributions.

Procedures

Left heart cath + ventriculogram + coronary angiography (93458)

Percutaneous coronary intervention: prox LAD, prox-mid LCX (92928, 92929)

Intra-aortic balloon pump (33967)

Vascular Access

Location: right radial artery, right femoral artery

Sheath: 5Fr (right radial), 6Fr (right femoral)

Disposition (end of case): radial – TR band; femoral – hemostasis with Brand EE closure device

Catheters Diagnostic: JL4, JR4, Amplatz 1, pigtail

Intervention: XB 3.5, Amplatz 2

Diagnostic Findings Hemodynamics (mm Hg)

Aorta: 134/78, mean 92

LV: 134/4, EDP 18

Coronary arteries Left ventricle

Left dominant EF: 61%

Prox LAD: 90% MR: 1+ mild

Prox-mid LCX: diffuse 80% Wall motion: mild anterior hypokinesis, moderate

OM3: 60% apical hypokinesis

RCA: normal

Interventions Prox LAD: Brand MM 3.0mm x 18mm (drug eluting) stent: 90% pre to 0% post

Prox-mid LCX: Brand NN 3.0mm x 28mm (bare metal) stent: diffuse 80% pre to 10% post

Adverse Events Ventricular fibrillation

Box 1

Box 2


Medication Totals Diphenhydramine: 25 mg Heparin: 5000 units

Hypdromorphone: 1 mg Clopidogrel: 600 mg

Midazolam: 1 mg Antacid: 30 ml

Contrast Total Iopamidol: 140 ml

Impressions

2 vessel coronary artery disease

Successful PCI x2

Recommendations Risk factor modification

Routine post-PCI care

Refer for cardiac rehab

Aspirin 81 mg lifelong

P2Y12 inhibitor for at least 6 months

Avoid elective surgery while receiving a P2Y12 inhibitor

Physician

___<eSignature>______________ _____<eSignature>___________

Richard Green, MD Pamela Blue, DO

Attending attestation: I was present for the entire procedure.


Cardiac Catheterization Laboratory [Name of facility]

[Logo of facility]

Patient: Last name, first name

[middle initial /name]

MRN: xxxxxxxxx DOB: xx/xx/xxxx Age: xx

Gender: M/F

Procedure Date: xx/xx/xxxx

Cine Number: xxxxx

Cath Attending: xxxxxxxxx xxxxxxxxx

Referring Provider: xxxxxxxx xxxxxxxxx

Patient

Last name, first name middle name / initial

Date of birth, age, gender

Race, ethnicity

Medical record number

Case accession number

Insurance

Healthcare Facility The Heart Hospital

Adult Cardiac Catheterization Laboratory

2000 Applewood Lane

Eureka, Texas 75100

(555) 555-1111

FAX: (555) 5555-1234

Laboratory: Cath Lab 2

Operator Staff

Richard Green, MD Carrie Brown, RN

Pamela Blue, DO (fellow) Samuel White, CVT

Samantha Rose, RN

Deborah Black, RN

Care Providers Referred by: John Grey, MD

2000 Southfork Ranch Road

Dallas, TX 71234

(813) 555-1212

Primary Care Provider: Barney Redd, MD

1000 Cahuna Ranch Boulevard

Arlington, TX 72345

(714) 555-1212

Cardiologist: Ray Ivory, DO

3000 Workman Ranch Street

Irving, TX 73456

(615) 555-1212

Reason for request: evaluation of decompensated heart failure with chest pain.

Procedure requested: left heart cath

Date of request: January 2, 2013

Requested by: John Grey, MD

Cardiovascular Catheterization Report Prototype v1.5

Encounter Category Elective cath, possible PCI

History and Physical Data

Symptom Class – Angina Onset: 12/??/2007

Current CCS class: asymptomatic

Symptom Class – Heart Failure Onset: 12/??/2007

Current NYHA class: asymptomatic

Medical History

Diabetes mellitus, type II: on oral meds

Total cholesterol >200

LDL >100

Cigarette smoking: average of 2.5 packs per day x 25 year

Hypertension

Renal insufficiency: CKD stage 3

Cardiac transplant: 1/4/2009

Steroid use, chronic

Previous Procedures / Previous Events

12/18/2007 High Point Regional Hospital: acute MI

12/18/2007 High Point Regional Hospital: LHC, PCI - mid LAD

7/10/2008 Duke University Medical Center: LHC

9/21/2008 Duke University Medical Center: RHC, LHC

1/4/2009 Duke University Medical Center: cardiac transplant

1/11/2009 Duke University Medical Center: RHC, biopsy

2/11/2009 Duke University Medical Center: biopsy

5/15/2009 Duke University Medical Center: stress echo, anterior and anterolateral ischemia

Allergies and Sensitivities

Penicillin: rash (moderate)

Physical Examination Lungs: clear

Heart: normal S1 and S2

Pulses:

carotid femoral DP PT

left 2 2 2 2

right 2 2 2 2

Bruits:

left 0 0

right 0 0

Neurologic: alert & oriented x3

Laboratories Hemoglobin 12.2 g/dL [13.7-17.3] 11/30/2011


Hematocrit 36 L/L [0.39-0.49] 11/30/2011

Platelets 349 X10^9 [150-450] 11/30/2011

Sodium 138 mmol/L [135-145] 11/30/2011

Potassium 4.5 mmol/L [3.5-5.0] 11/30/2011

Urea nitrogen 33.0 mg/dL [7-20] 11/30/2011

Creatinine 1.9 mg/dL [0.6-1.3] 11/30/2011

Prothrombin 11.9 sec [9.5-13.1] 11/30/2011

ICD Diagnoses (*indicates primary indication)

*V42.1 Heart replaced by transplant

585.3 Chronic kidney disease, stage 3 (GFR 59-30)

401.1 Benign essential hypertension

426.4 Right bundle branch block (RBBB)

V58.65 Steroids, long term (current) use of

V58.66 Aspirin, long term (current use)

AUC Indications Diagnostic cath: criterion 101 (post heart transplant patient)

Intervention: criterion 10 (UA/NSTEMI and intermediate risk features)

PROCEDURE DETAILS

Procedures Endomyocardial biopsy Left heart catheterization

Right heart catheterization Coronary angiogram - left

Fick cardiac output Coronary angiogram - right

Aortic pressure measurement Drug-eluting stent – single vessel

Logistics

Time arrived in lab: 11:40, from CVSSU

Consent signed: yes

Sedation consent: yes

Timeout performed: yes

Time departed from lab: 13:11, to CVSSU

Final patient condition: stable

Baseline Data Height: 172.0 cm

Weight: 73.7 kg

BSA: 1.80 m2

Initial blood pressure: 125/67 mmHg

Initial pulse: 66 bpm

eGFR: 77 mL/min

Vascular Access Right femoral vein: SheathCo 7Fr Slider sheath, Hemo 7Fr Intro 85cm (biopsy sheath)

Disposition: removed, hemostasis via manual compression

Right femoral artery: SheathCo 5Fr Slider sheath

Disposition: removed, hemostasis via manual compression


Hemodynamic Support Left femoral artery: Datascope 40 cc intra-aortic balloon pump, inserted at 11:45

Disposition: left in place


Diagnostic Findings

Right Heart Catheterization

Instruments: Bard 7Fr Pulmonary Wedge Pressure Catheter

Oximetry, Cardiac Output, and Calculated Data

Assessment conditions: rest

Patient height: 172.0 cm, weight: 73.7 kg, body surface area: 1.80 m²

Vital signs: HR: 92 bpm, BP: 131/104 mmHg

Inspired O2: room air

Vasoactive agents: none

Oximetry samples (rest)

Sample Site Hgb (g/dL) O2 Sat (%)

FA 11.1 95.6

PA1 11.0 53.2

PA2 11.0 53.0

Assumed O2 consumption = 226.0 mL O2/min

BMR = 0.5 %

A-V O2 Difference = 6.39 Vol % PBF (Qp) = 3.5 L/min

PVR = 3.1 Wood units SBF (Qs) = 3.5 L/min

SVR = 21.8 wood units Cardiac Index = 1.89 L/min/m2

Hemodynamic and Valve Data (resting state, in mmHg)

RA: a=10, v=10, mean=8

RV: 32/7, EDP 10

PA: 32/17, mean=20

PCW: a=8, v=12, mean =10

Systemic BP: 120/78, mean 95

Coronary Angiography Instruments: 6Fr JL4, 6Fr JL5, 6 Fr JR4, 6Fr dual lumen pigtail

Coronary anatomy

Dominance: right

Segment Stenosis Lesion Type TIMI Flow (abnormal)

Prox RCA 30% Discrete

Mid RCA 40% Discrete

RPL1 (Small) 50% Diffuse

RPL2 (Small) 50% Diffuse

Mid LAD 20% Discrete

*Mid LAD 70% Discrete

Dist LAD 30% Tubular

Left Main normal

Left Circumflex normal

* Denotes significant lesion

Notes: anterior takeoff of the RCA, unable to seat JR catheter

Box 3


Left Ventriculography Instruments: 6Fr dual lumen pigtail

Hemodynamics (mm Hg): 182/6, EDP 22

Ejection fraction: 55%

Wall motion: mild inferior hypokinesis, moderate apical hypokinesis

LV dilation: mild global dilation

Mean Ao-LV gradient: 45 mm Hg

Aortic valve area: 0.7 cm2

Interventions

Percutaneous Coronary Intervention Lesion #1: OM2 90% TIMI 3 (pre) to normal TIMI 3 (post) (IRA)

Guide catheters: Cordis 6Fr XB 3.0 Vista Britetip

Guide wires: Guidant/ACS .014x300cm Whisper MS

Devices:

Abbott Mini Trek OTW 2.0x20mm (balloon)

Medtronic Resolute Integrity 2.25x30mm (drug eluting stent) – max atm: 18

Notes: Lesion did not open until 24 ATM applied with pre-dilation balloon

Lesion #2: L main body normal TIMI 3 (pre) to 50% TIMI 3 (interval) to normal TIMI 3 (post)

Guide catheters: Cordis 6Fr XB 3.0 Vista Britetip

Guide wires: Guidant/ACS .014x300cm Whisper MS, Abbott Balance Middleweight Universal

Devices:

Abbott Xience Rx Everolimus 4.0x12mm (drug eluting) stent

Abbott NC Trek Rx 5.0x8mm (balloon)

Notes: guide catheter trauma to left main; both LAD and LCX were wired

Right Ventricle Biopsy Instruments: Bioptome Forcep MOB-1

Specimens removed: 4

Pathology slip: 44335544

Medication Totals

Medication Dose Route Time Comment

Lidocaine 1%, 20 ml sq 14:10

Diphenhydramine 25 mg iv 14:03

Hydromorphone 0.5 mg iv 14:03

Midazolam 1.0 mg iv 14:03

0.9% normal saline 50 ml iv

Isovue 80 ml Lot number: 1F31882

Radiation Fluoroscopy time: 4.5 minutes

Dose area product: 1.1 Gy-cm2

Cumulative air kerma: 1340 mGy

Box 4

Box 3


Estimated Blood Loss: 20 ml

Specimens Removed: RV biopsy x4

Final ICD Diagnoses 585.3 Chronic kidney disease, Stage 3 (moderate) - (GFR 59-30)

V42.1 Heart replaced by transplant

426.4 Right Bundle Branch Block (RBBB)

V58.65 Steroids, Long term (current) use of

401.1 Benign Essential Hypertension

V58.66 Aspirin, Long term (current use)

Procedure Notes

[This is for any additional text-based notes describing the specifics of the procedure]

Cardiovascular Catheterization Report Prototype v. 1.5 Box 1 Box 2

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